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Home My WebLink AboutBuilding Permit # 9/8/2015 OORTH BUILDING PERMIT 0 TOWN OF NORTH ANDOVERo APPLICATION FOR PLAN EXAMINATION Permit N M61 IIId I Date Received 1 to TE0,01'"', �SS•�coaUSEc Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION 50 56-WVyN`(11 ?,(.I- Print PROPERTY OWNER V\aV et'Xlh e t. - UG- MAP PARCEL: ZONING Print 100 Year Structure yes DISTRICT: Historic District yes rio Machine Shop Village yes 0.) TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 0 New Building 11 One family 11 Addition [I Two or more family 11 Industrial D Alteration No. of units: 11 Commercial El Repair, replacement [I Assessory Bldg 11 Others: D Demolition 11 Other lSe 1111110 , � , ,,, � �i�i,/�/1>/�/%f��/��i/�l�/��f//rid',/ DESCRIPTION OF WORK TO BE PERFORMED: S1 Identification- Please Type or Print Cly arly Phone:cl J .- 69LI,. 14.Ll- Address: G50 SCA 'M PJ Nov, a An d o V,e (-)I '4S Contractor Name: Phone: Email: Address: 0A C z- 1; V� Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCH ITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDINGPERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $L Check No.: Receipt No.:—;�J 6'1 NOTE: PersoiWco�n actin with unregistered contractors do not have access tol the gharantyfund --- A Sic t%ORTH 11 F Town of ndover ® 0% No. C% LAKE h h ver� ss, COCNICNEWICN y�' RATED ►e�,�,C� S U BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT .....#.t.8ft..0 .. .. ..... .................... ,.... BUILDING INSPECTOR Foundation has permission to erect.......................... buildings on . ....... t. .................................. Rough to be occupied as .......... .. ... ......... .. .. .....°................................................................... Chimney Y I provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final Ah FLA PERMIT EXPIRES �I 6 N ELECTRICAL INSPECTOR LESS C S CTI Rough Service ................. ........ ...... ...... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required t® Occupy Building, Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. NORTH TOWN OF NORTH ANDOVER OFFICE OF OWN BUILDING DEPARTMENT 0 1600 Osgood Street, Building 20, Suite 2035 North Andover, Massachusetts 01845 Gerald A.Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: 150 sa\tj Il'i Number Street Address Map/Lot NA&YK atiqer HOMEOWNER L,a R-os 6t- 9-18,-- (0s i� - Name Home Phone Work Phone PRESENT MAILING ADDRESS S kS6,WPA"( I I Nwcty� Aodove_e, mo C8 19 WS City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provide that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or faun structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR Section I I O.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 The Commonwealth of Massachusetts Department ofIndlustrialAccidents I Congress Street,Suite 100 Boston,AIA 02114-2017 . . .... vww.mass.go-p1dia Workers,Compensation fusurmice Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED VnTEME PERIMTTJVG AUTE(OPUTY. Applicant Information Please Print Legibly NaMC)(Bilsiness/Organization&dividual): MaYL_.&- JJC0_'he1' L&V,1ZSa- Address: ( fi,S0yY6t( KA , City/State/Zip: �A ov Ah. And oVe r, M4 Phone#: q-7 65-5 'A- (L14 Are you an employer?C&ck V6 appropriate box; Type of project(Tqquired): l.r1lamaemployer with employees(Mandlorpart-time).* 7. New constmotion 2.Q am a sole proprietor or partnership and have no employees working for me in 8. Remodelffig ,any capacity.[No workers,comp.insurance r'equired.] 9. El Demolition 3. Iam a homeowner doing all work myself,[Noworkers'comp.insurance required.]t 10 F1 Building addition 4.E]I am a homeowner andwill be hiring contractors to conduct all-work on my property. I-Will ensure that all contractors either have workers'compensation insurance or are sole 11.F1 Electrical repairs or additions proprietors withno employees. 12. Plumbing repairs or additions 5.0 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs ThesesLb-c'ontractors hav:e employees and have workers-comp,insuranca.� -]Other 6.n We are a corporation and its officers have exercised their right of exemption perMGL c. 14.[_ 152,§1(4),and we have ucL employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing theirworkers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work andthenhire outside contractors must submit anew affidavit indicating such. TContractois that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-c6n6d&s have employees,lliqy mnft provide their Y;orkcis'comp.policy number. .1 am an employer thatispi6vidingworkers9 compensation insuran cefor my employees.'.Below is the policy an djob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' 60rapeMation-Policy declaration page(showing the policy number and expiration(late). Failure to secure coverage as required under MGL o.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fbim of a STOP WORK ORDER and afine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of luvestigations of the DIA for insurance coverage verification. I do hereby cert ijy under the pains andpenattles qfpejjuiy that the information provided above is true and correct. e, Date: 9114115 Signature �ke 9 1 Phone#: 1-1 a - (P5 b 14 4 Official use only. Do not vfite in this area,to he completed by city oi-town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/'Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: